Lucy Chechik is a fourth year Chemistry major from Minneapolis, MN. After Grinnell, she wants to become a physician focused on maternal health.
“The difficult thing for us to realize is the position of trust and respect in which the midwife is held in Denmark” –Dr. Dorothy Mendenhall, 1928 [1].
In the early 1920s, Dr. Dorothy Mendenhall traveled to Denmark to learn about how Scandinavian countries were obtaining such low maternal and infant mortality rates. On her first day in Copenhagen, she was surprised to learn that midwives were still very much in charge of births. In both the United States and Denmark, community women have historically assisted in births, learning from their mothers and female neighbors how to best attend to a woman in labor. As science and medical education progressed, however, the American and Danish approaches to midwifery began to deviate. American midwives watched as mothers opted to receive maternal care from obstetricians, whereas Danish midwives retained their position as experts in childbirth [2, 3]. To this day, American midwives attend a limited number of deliveries while their Danish counterparts are regarded as the childbirth experts and oversee almost all of Denmark’s births. Due to paradoxical histories, American and Danish midwives now experience different statuses within hospitals, as American midwives struggle to remain prevalent in a medicalized model of childbirth institutionalized by physicians throughout history while Danish midwives enjoy autonomy and respect as they attend almost all births as the primary healthcare professional.
In the United States, midwifery was the traditional model of maternal care. Births were a social event where women within the community came together to support each other and assist throughout labor and delivery, and while there was often an informally trained midwife in attendance, many women had gained experience with the birthing process by simply attending births within the community, often beginning during adolescence [4]. What is often referred to as the “medicalization of childbirth,” began to take hold in the mid-19th century as physicians used their status within society to push for legislation that effectively eliminated midwives from the sphere of childbirth [5]. Not only was it the physicians’ gender, race, and socioeconomic status, but it was also their association to scientific knowledge and advancements in technology that overpowered midwives’ claim to authority over childbirth [6]. Americans, often wooed by status and knowledge, listened to these physicians’ claims of expertise and chose to have obstetricians provide their maternal care. This decision ultimately altered the nation’s perspective on childbirth, painting an image of hospital-based forceps and anesthesia surrounded by white coated-physicians over the traditional, natural birth attended by community women.
In the early 20th century, American physicians started to observe an increase in maternal and infant mortality, and although these spikes correlated with the transition from home births to hospital births, physicians claimed that these increasing rates were clear evidence of a “midwife problem” [7].
It was then that Dr. Mendenhall traveled to Denmark, hoping to understand how doctors in the United States could ensure higher survival rates in their mothers and infants. The answer, of course, was the natural birth model supported by midwifery care. Since 1714, midwives in Denmark have been held to national standards, with formal education beginning in 1787. By the time Dr. Mendenhall arrived in Copenhagen in the 1920s, midwives had been receiving standardized instruction from other physicians, nurses, and midwives for more than 140 years [8]. When Dr. Mendenhall questioned Dr. E Hauch, a professor of obstetrics that oversaw half of the maternity care at the Royal Hospital, about Danish infant and maternal mortality rates, he informed her that American physicians interfered too much. He told Dr. Mendenhall that he didn’t allow forceps in his part of the hospital, instead allowing nature to do its job [9].
It’s in Dr. Mendenhall’s response that we see how the differing histories contribute to national perspectives on midwives and their role in childbirth, as she argued that “no thinking person would say the European-trained midwife is comparable to our best trained obstetrician” [10]. This begs the question, why do Americans require their “best-trained obstetricians” to facilitate an essential part of our life cycle that our species has evolved to perfect? The status of midwifery has suffered in the United States because soon-to-be parents want the best for their children and societal preferences align with Dr. Mendenhall’s sentiment: the best choice for childbirth is an obstetrician.
Throughout history, physicians set the narrative that midwives are inferior care providers. Now, midwives must obtain hospital permissions and depending on the state, must have a “collaborative agreement” with a physician to practice [11]. Additionally, these regulations are for Certified Nurse Midwives (CNMs), meaning the midwife has already obtained a nursing degree and then received additional training in midwifery [12]. Such a distinction is important because it shows that the midwives allowed to practice in hospitals were required to obtain certifications that place them within the physician-nurse model of care, since they couldn’t simply be midwives, they had to be nurse midwives. Furthermore, in a discussion with 70 CNMs, only five believed they were providing the women-centered, holistic midwifery care they originally set out to do as midwives. Upon hearing this, the other 65 women spent the remaining time of the conversation asking how these five midwives did it without worrying about losing their jobs [13]. In another survey concerned with workplace resiliency, many midwives reported feeling stressed at due to the perceived bullying culture [14]. Although midwives now attend a little less than 10% of births in the US (up from less than 1% in 1975), these women must oblige with the medically-biased care standards set by hospitals and physicians because otherwise they risk losing the physician and hospital approval they require in order to practice.
In Denmark, midwives enjoy respect, authority, and autonomy within the sphere of childbirth. During cases spanning the 19th and 20th centuries, midwives were consulted by physicians, showing that the physician respected the midwives’ professional opinions [15]. In the 1930s, there was a debate between doctors regarding the role of midwives in which the majority determined that the midwives should have a function in providing preventative care to pregnant women, further supporting the amount of trust physicians placed in midwives [16].
This trend has continued into the modern era. In a Danish national quality database report released in 2016, the authors stated that all data was reported by the attending midwife immediately following birth [17]. This illustrates a clear level of authority that the national data would be comprised of information controlled by midwives. Additionally, when adopting new standards and indications, the group in charge of the decision was a collection of midwives, obstetricians, a pediatrician, anesthesiologists, and an epidemiologist [18]. Their inclusion demonstrates the authority midwives enjoy within the sphere of childbirth, further supported by guidelines set by this coalition that gave the midwife complete authority not only in normal pregnancies, but also those with complications [19]. This authority feeds into a level of autonomy not experienced by American midwives, but something that allows Danish midwives to truly practice “good, old-fashioned” midwifery care that focuses on the mother and supports her throughout a natural childbirth with access to modern medicine if desired or deemed necessary [20].
Midwifery history and status varies greatly between the United States and Denmark, but in both countries, patients expressed high levels of satisfaction with their care. In the US, mothers reported that their midwives “validated who they were,” “[believed] in the woman’s abilities,” and felt more respected in terms of the woman’s knowledge of her own body and children [21]. Many Danish women echoed these sentiments, adding that their relationship with their midwife was like a “professional friendship, characterized by quality and inclusiveness” [22]. Danish mothers felt like equals with their midwives, but still exhibited deep trust that their midwives would make the right professional decisions for their health and that of their baby [23]. This mutually respectful relationship is not only what makes the midwife so well-liked by patients, but it also is what makes them different from other healthcare professionals.
Dr. Mendenhall reflected on the American medical system, recognizing that “hurry has become part of our national temperament” [24]. Between 2003 and 2009, cesarean sections increased by 10% to account for more than 1/3 of total births in the US [25]. Instead of hours of labor, a cesarean is scheduled in advance and takes twenty minutes, making it quicker and easier for both the mother and physician [26]. It takes a naturally occurring event, however, and makes it into a medical procedure- an act that disempowers the woman and gives her authority over her own body to her physician.
This isn’t a new trend. When a woman chose to birth in hospitals attended by male physicians over doing so at home assisted by her female community members, she gave up her innate ability for childbirth. In the years that followed, women asked for forceps, anesthesia, and eventually voluntary cesarean sections. This is not to say that it is the woman’s fault that physicians hold authority over childbirth in the United States, but rather to show that if women gave physicians that power originally, women are the ones that can take it away. The care midwives provide is highly regarded by their patients and makes women feel empowered by the strength of their own bodies, but the overall status of midwives in America is abysmal due to years of forced elimination from the sphere of childbirth. Until mothers insist on midwives as their primary maternal care providers, we will continue down this path away from the autonomy and authority of natural childbirth.
References
[1] Mendenhall, Dorothy Reed. 1929. Midwifery in Denmark. Washington: U.S. Gov. Print. Off.
[2] Laura Ettinger, “Conception: Nurse-Midwives and the Professionalization of Childbirth,” chapter 1 in Nurse-Midwifery: The Birth of a New American Profession (Ohio State University Press, 2006), 1-28.
[3] Bondo, Lillian, and Mette Egelund. “Professionsudvikling hos jordemødre-ser de frem, tilbage-eller ser de ud?.” (2008): 114.
[4] Laura Ettinger, “Conception: Nurse-Midwives and the Professionalization of Childbirth,” chapter 1 in Nurse-Midwifery: The Birth of a New American Profession (Ohio State University Press, 2006), 1-28.
[5] DeVries, R. G. (1992). Barriers to midwifery: An international perspective. The Journal of Perinatal Education, 1(1), 1-10.
[6] Thomas, Samuel S. “Early modern midwifery: splitting the profession, connecting the history.” Journal of social history 43, no. 1 (2009): 115-138.
[7] Laura Ettinger, “Conception: Nurse-Midwives and the Professionalization of Childbirth,” chapter 1 in Nurse-Midwifery: The Birth of a New American Profession (Ohio State University Press, 2006), 1-28.
[8] Mendenhall, Dorothy Reed. 1929. Midwifery in Denmark. Washington: U.S. Gov. Print. Off.
[9] Ibid.
[10] Ibid.
[11] “States that Allow CNMs to Practice and Prescribe Independently vs those that Require a Collaborative Agreement,” Midwife Schooling, accesed 4/23/18, https://www.midwifeschooling.com/independent-practice-and-collaborative-agreement-states/.
[12] Davis-Floyd, Robbie. “The ups, downs, and interlinkages of nurse-and direct-entry midwifery: Status, practice, and education.” Getting an education: Paths to becoming a midwife (1998): 67-118.
[13] Ibid.
[14] Hunter, Billie, and Lucie Warren. “Midwives׳ experiences of workplace resilience.” Midwifery 30, no. 8 (2014): 926-934.
[15] Bondo, Lillian, and Mette Egelund. “Professionsudvikling hos jordemødre-ser de frem, tilbage-eller ser de ud?.” (2008): 114.
[16] Ibid.
[17] Andersson, Charlotte Brix, Christina Flems, and Ulrik Schiøler Kesmodel. “The Danish national quality database for births.” Clinical epidemiology 8 (2016): 595.
[18] Ibid.
[19] Jepsen, Ingrid, Edith Mark, Ellen Aagaard Nøhr, Maralyn Foureur, and Erik Elgaard Sørensen. “A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives.” Midwifery 36 (2016): 61-69.
[20] Ibid.
[21] Kennedy, Holly Powell. “A model of exemplary midwifery practice: Results of a Delphi study.” Journal of Midwifery & Women’s Health 45, no. 1 (2000): 4-19.
[22] Jepsen, Ingrid, Edith Mark, Maralyn Foureur, Ellen A. Nøhr, and Erik E. Sørensen. “A qualitative study of how caseload midwifery is experienced by couples in Denmark.” Women and Birth 30, no. 1 (2017): e61-e69.
[23] Ibid.
[24] Mendenhall, Dorothy Reed. 1929. Midwifery in Denmark. Washington: U.S. Gov. Print. Off.
[25] Barber, Emma L., Lisbet Lundsberg, Kathleen Belanger, Christian M. Pettker, Edmund F. Funai, and Jessica L. Illuzzi. “Contributing indications to the rising cesarean delivery rate.” Obstetrics and gynecology 118, no. 1 (2011): 29.
[26] Epstein, Abby, and Ricki Lake. “The business of being born.” Burbank, Calif.: New Line Home Entertainment (2008).
Further Reading:
- Bourgeault, Ivy Lynn, Cecilia Benoit, and Robbie Davis-Floyd. Reconceiving midwifery. McGill-Queen’s Press-MQUP, 2004.
- Benoit, Cecilia, Sirpa Wrede, Ivy Bourgeault, Jane Sandall, Raymond De Vries, and Edwin R. van Teijlingen. “Understanding the social organisation of maternity care systems: midwifery as a touchstone.” Sociology of health & illness 27, no. 6 (2005): 722-737.
- Van Teijlingen, Edwin R. Midwifery and the medicalization of childbirth: Comparative perspectives. Nova Publishers, 2004.
